Quora Query: Who Should be in Charge of Administrating a Hospital?

The question is ( or should be): What does it take to administer a hospital and who should do it ?

[In a previous comment] Doctor Ford is correct that much of care provision is performed by our nursing colleagues, but to state that “Doctors (all types), technicians and other professions allied to medicine should be directed to apply their skills within a care process matrix defined and controlled by nursing…” as he does, seems to me to be fabulously off the mark. The administrative skill sets of nurses are no better than is anyone else, except with the appropriate training.

Anon [in another comment] states that the administrator should be someone who knows how to manage. But this is a tautological statement, as far as I can see.

Rather, having worked in several systems, I think that the best system is one that builds administrative – clinical teams and gives them real responsibility AND authority.

At neither the University of Florida Medical Center, nor at Cook County Hospital, both places in which I have spent significant time, were teams built. Rather, a system of departmental silos were built which the administration used to play off physicians against physicians, nurses against nurses, and nurses against physicians. I think this is pretty standard operating procedure in many, but by no means all, systems.

The best systems, on the contrary, create teams of administratively trained people (MBAs, MHAs, and so forth) and PAIR them with clinicians – physicians and nurses. In this way, financial, organizational, and logistical issues are dealt with along side of the clinical ones. Each member of the team contributes their expertise to the management of the institution or health system.

Is this perfect ? Of course not. Does it work better than the alternatives ? Most assuredly.

The system of which I [was] a part runs its management in this manner, from the highest levels through Divisional and Departmental structures; it more-or -less worked.

One can get some sense that it works by looking at the quality, outcome, and financial metrics as well as the satisfaction surveys of the people working in the system.

[Response from Doctor Ford]:

Abraham – Dear Colleague

Having never been called ‘fabulous’ before I felt compelled to respond!

A little background:

The NHS arose in a chaotic manner. After WW2 thousands of hospitals, clinics, primary care providers and others were instantaneously pooled into a single structure. There was an administration from Department of Health down to local structures such as hospital and health authority boards. Vast complicated systems of rules and regs that were centrally devised were administered into action with lots of variation and pragmatic fixes.

After a fashion this worked and by an organic process of adaptation the NHS evolved slowly. The draw backs were, firstly, successive governments were completely clueless about how to run the system and, secondly, there was never the right funding in the right place.

In the sixties a major upheaval began to bring primary care in from the ‘front parlour artisan singlehander’ era. Huge hospital complexes were constructed from the outset but they tended to be modelled on Florence Nightingale era medical barracks and Victorian asylums.

By the end of the 70s Thatcher began to question the whole thing and set course for privatisation – a process continuing to this day [this was written in 2012]. At this point someone noticed that an organisation consuming billions and employing hundreds of thousands did not have any managers and there was precious little information available about what was being done, to whom, with what, where, at what cost and with what result.

Serried ranks of jackbooted Quislings were directed to achieve a managerialist Anschluss on the NHS. Neither Thatcher nor the managers (ex-industry types or political pole climbers) grasped the essential difference between an industrial process, care and ideological vainglory. This is probably the origin of our current problems. There is little evidence-based policy but a super-abundance of policy based evidence.

Speak to almost any clinician in the NHS confidentially and they will tell you about the problems that managers cause. In their haste to curry favour with those further up the pole some have even been imprisoned for fraud – amongst other things. I am aware of multi-million discrepancies in accounts and instances of serious malfeasance.

One of the most destructive influences has been the fragmentation of care and the teams that delivered it but this is a political imperative to facilitate the privatisation of healthcare.

Clinicians wishing to communicate effectively do so with private phones or word of mouth. We are in an era of Samizdat communication in a modern western democracy in the early 21st century.

In a nutshell: we have a massive problem that is caused by management – management is the problem. Kick-arse management in a collegiate setting is fatal. There was a brilliant TV analysis of this issue by a famous industrialist which you might be able to find on-line somewhere.

However:

I think you have highlighted something very important in your answer: getting all the functions co-operating. Creating an identity of interest (or balance of mutual terror – if you prefer).

Perhaps I should restate my idea a little: The spine of the care process in all healthcare settings should be predicated on the nursing process with the other clinical functions coalescing around this.

Nurses are no more trained to be managers than are doctors (at least hitherto) but they should be the lead function.

What is the role of management? Management should be the unseen infrastructure – getting the right patients, clinicians and other resources into the right place on time. They are the logisticians and adminstrators – for them to even aspire to intrude into the clinical realm is to invite disaster.

Managers, generically, are no better equipped to run healthcare than anyone else. To optimise their roles in a healthcare setting they need to unlearn much of what happens in commerce and be part of the team.

Healthcare never was and never can be a business. It is a service.

So you see Abraham, there is much common ground between us and I suspect that any differences arise from my imperfect prose.

What do you think? Steve

 

[Response to Doctor Ford]:

Steve –

I get it completely.

First of all, you come from the British NHS, I come from the completely fragmented, siloed, and “widget-based” American system.

I am no fan of Mrs. thatcher, although it was clear, at least to this outsider, that some kind of coordination needed to be created in the NHS.

At last year’s Institute for Healthcare Improvement (IHI) session on the NHS, some very very cool data were shared with us from the Scottish contingent of the NHS on organizational issues.

But the issues remain the same:

1. It is physicians, nurses, and other practitioners that create “value” (forgive me the use of that word) in a health system;

2. Yes, we live in a monopoly-capitalist world, but there are some things that simply cant be turned into commodities; healthcare is one of them. The provision of health is a true public service….we are the firefighters of the health system!

3. The leadership of your country and mine need to decide what the goals for the health system are, fund the system properly, and then get out of the way so that we can meet the goals. And people like you and me need to be held accountable for the goals and metrics related to the goals.

Leaders lead from the front, not by sitting behind a desk. I [was] – oddly enough for my self image – a “clinician – administrator” (sort of like being a flying horse). I ask[ed] nothing of my clinical colleagues that I do not do [first], whether night duty, or anything else.

The American system is awash in wasted money, unneeded procedures, un-integrated care, and poor quality. Oh yes, AND we have about 1/3 of our population that is either uninsured or grossly underinsured.

And we call ourselves a civilized country.

Not-withstanding the serious limitations with and problems of President Obama’s Health (insurance) Reform, we have taken a step forward [again, this was written in 2012].

You in the NHS have problems as do we, they are just different problems.

But we agree on much, my dear colleague. And for sure on this: We are honored to have the responsibility to care for our people. There is – to my mind – no higher calling. Nothing more honorable than the work we do; despite all of the problems.

 

About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the approximately 10 years until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director and Co-Chairman of Critical Care Medicine in PA; this ended in 2017. He serves as a Physician in the Surgical Group with Médecins sans Frontières (MSF, Doctors without Borders). While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". Follow on Twitter @ajlayon
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